HESI EXIT V6 COMPLETE EXAM QUESTIONS AND ANSWERS
A parent tells the nurse that their 6 year-old child who normally enjoys school, has not been doing well since the grandmother died 2 months ago. Which statement most ac
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HESI EXIT V6 COMPLETE EXAM QUESTIONS AND ANSWERS
A parent tells the nurse that their 6 year-old child who normally enjoys school, has not been doing well since the grandmother died 2 months ago. Which statement most accurately describes thoughts on
death and dying at this age?
Death is personified as the bogeyman or devil
Death is perceived as being irreversible
The child feels guilty for the grandmother's death
The child is worried that he, too, might die
The correct answer is A: Death is personified as the bogeyman or devil
A 67 year-old client with non-insulin dependent diabetes should be instructed to contact the out-patient clinic immediately if the following findings are present
Temperature of 37.5 degrees Celsius with painful urination
An open wound on their heel
Insomnia and daytime fatigue
Nausea with 2 episodes of vomiting
The correct answer is B: An open wound on their heel
The nurse admits an elderly Mexican-American migrant worker after an accident that occurred during work. To facilitate communication the nurse should initially
Request a Spanish interpreter
Speak through the family or co-workers
Use pictures, letter boards, or monitoring
Assess the client's ability to speak English
The correct answer is D: Assess the client''s ability to speak English
In assessing a post partum client, the nurse palpates a firm fundus and observes a constant trickle of bright red blood from the vagina. What is the most likely cause of these findings?
Uterine atony
Genital lacerations
Retained placenta
Clotting disorder
The correct answer is B: Genital lacerations
The nurse notes an abrupt onset of confusion in an elderly patient. Which of the following recently-ordered medications would most likely contribute to this change?
Anticoagulant
Liquid antacid
Antihistamine
Cardiac glycoside
The correct answer is C: Antihistamine
The nurse is caring for a client with active tuberculosis who has a history of noncompliance. Which of the following actions by the nurse would represent appropriate care for this client?
Instruct the client to wear a high efficiency particulate air mask in public places.
Ask a family member to supervise daily compliance
Schedule weekly clinic visits for the client
Ask the health care provider to change the regimen to fewer medications The correct answer is B: Ask a family member to supervise daily compliance
The nurse manager identifies that time spent by staff in charting is excessive, requiring overtime for completion. The nurse manager states that "staff will form a task force to investigate and develop potential solutions to the problem, and report on this at the next staff meeting." The nurse manager's leadership style is best described as
Laissez-faire
Autocratic
Participative
Group
The correct answer is C: Participative
A nursing student asks the nurse manager to explain the forces that drive health care reform. The appropriate response by the nurse manager should include
The escalation of fees with a decreased reimbursement percentage
High costs of diagnostic and end-of-life treatment procedures
Increased numbers of elderly and of the chronically ill of all ages
A steep rise in health care provider fees and in insurance premiums
The correct answer is A: The escalation of fees with a decreased reimbursement percentage
A client with hepatitis A (HAV) is newly admitted to the unit. Which action would be the priority to include in the plan of care within the initial 24 hours for this client?
Wear masks with shields if potential splash
Use disposable utensils and plates for meals
Wear gown and gloves during client contact
Provide soft easily digested food with frequent snacks
The correct answer is C: Wear gown and gloves during client contact
A client has been taking alprazolam (Xanax) for 3 days. Nursing assessment should reveal which expected effect of the drug?
Tranquilization, numbing of emotions
Sedation, analgesia
Relief of insomnia and phobias
Diminished tachycardia and tremors associated with anxiety The correct answer is A: Tranquilization, numbing of emotions
The nurse observes a staff member caring for a client with a left unilateral mastectomy. The nurse would intervene if she notices the staff member is
Advising client to restrict sodium intake
Taking the blood pressure in the left arm
Elevating her left arm above heart level
Compressing the drainage device
The correct answer is B: Taking the blood pressure in the left arm
A 70 year-old post-operative client has elevated serum BUN, Hct, Cl, and Na+. Creatinine and K+ are within normal limits. The nurse should perform additional assessments to confirm that an actual
problem is:
Impaired gas exchange
Metabolic acidosis
Renal insufficiency
Fluid volume deficit
The correct answer is D: Fluid volume deficit
The nurse is providing foot care instructions to a client with arterial insufficiency. The nurse would identify the need for additional teaching if the client stated
"I can only wear cotton socks."
"I cannot go barefoot around my house."
"I will trim corns and calluses regularly."
"I should ask a family member to inspect my feet daily."
The correct answer is C: "I will trim corns and calluses regularly."
A woman who delivered 5 days ago and had been diagnosed with preeclampsia calls
the hospital triage nurse hotline to ask for advice. She states “ I have had the worst headache for the past 2 days. It
pounds and by the middle of the afternoon everything I look at looks wavy. Nothing I have taken helps.” What should the nurse do next?
Advise the client that the swings in her hormones may have that effect. However, suggest for her to call her health care provider within the next day.
Advise the client to have someone bring her to the emergency room as soon as possible
Ask the client to stay on the line, get the address and send an ambulance to the home
Ask what the client has taken? How often? Ask about other specific complaints. The correct answer is C: Ask the client to stay on the line, get the address and send an ambulance to the home
The primary teaching for a client following an extracorporeal shock-wave lithotripsy (ESWL) procedure is
Drink 3000 to 4000 cc of fluid each day for one month
Limit fluid intake to 1000 cc each day for one month
Increase intake of citrus fruits to three servings per day
Restrict milk and dairy products for one month
The correct answer is A: Drink 3000 to 4000 cc of fluid each day for 1 month
A client on warfarin therapy following coronary artery stent placement calls the clinic to ask if he can take Alka-Seltzer for an upset stomach. What is the best response by the nurse?
Avoid Alka-Seltzer because it contains aspirin
Take Alka-Seltzer at a different time of day than the warfarin
Select another antacid that does not inactivate warfarin
Use on-half the recommended dose of Alka-Seltzer
The correct answer is A: Avoid Alka-Seltzer because it contains aspirin
The nurse is working with parents to plan home care for a 2 year-old with a heart problem. A priority nursing intervention would be to
Encourage the parents to enroll in cardiopulmonary resuscitation class
Assist the parents to plan quiet play activities at home
Stress to the parents that they will need relief care givers
Instruct the parents to avoid contact with persons with infection
The correct answer is A: Encourage the parents to enroll in cardiopulmonary resuscitation class
The nurse is caring for a client with Rheumatoid Arthritis. Which nursing diagnosis should receive priority in the plan of care?
Risk for injury
Self care deficit
Alteration in comfort
Alteration in mobility
The correct answer is C: Alteration in comfort
An unlicensed assistive staff member asks the nurse manager to explain the beliefs of a Christian Scientist who refuses admission to the hospital after a motor vehicle accident. The best response of the nurse would be which of these statements?
"Spiritual healing is emphasized and the mind contributes to the cure."
"The primary belief is that dietary practices result in health or illness."
"Fasting and prayer are initial actions to take in physical injury."
"Meditation is intensive in the initial 48 hours and daily thereafter."
The correct answer is A: "Spiritual healing is emphasized and the mind contributes to the cure."
In order to be effective in administering cardiopulmonary resuscitation to a 5 year- old, the nurse must
Assess the brachial pulses
Breathe once every 5 compressions
Use both hands to apply chest pressure
Compress 80-90 times per minute
The correct answer is B: Breathe once every 5 compressions
The nurse is providing home care for a client with heart failure and pulmonary edema. Which nursing diagnosis should have priority in planning care?
Impaired skin integrity related to dependent edema
Activity intolerance related to oxygen supply and demand imbalance
Constipation related to immobility
Risk for infection related to ineffective mobilization of secretions
The correct answer is B: Activity Intolerance related to oxygen supply and demand imbalance
.
For which of the following mother-baby pairs should the nurse review the Coomb's test in preparation for administering RhO (D) immune globulin within 72 hours of birth?
Rh negative mother with Rh positive baby
Rh negative mother with Rh negative baby
Rh positive mother with Rh positive baby
Rh positive mother with Rh negative baby
The correct answer is A: Rh negative mother with Rh positive baby
An 80 year-old nursing home resident has a temperature of 101.6 degrees Fahrenheit rectally. This is a sudden change in an otherwise healthy client. Which should the nurse assess first?
Lung sounds
Urine output
Level of alertness
Appetite
The correct answer is C: Level of alertness
?
What is the major purpose of community health research?
Describe the health conditions of populations
Evaluate illness in the community
Explain the health conditions of families
Identify the health conditions of the environment
The correct answer is A: Describe the health conditions of populations
The recent increase in the reported cases of active tuberculosis (TB) in the United States is attributed to which factor?
The increased homeless population in major cities
The rise in reported cases of positive HIV infections
The migration patterns of people from foreign countries
The aging of the population located in group homes
The correct answer is B: The rise in reported cases of positive HIV infections
A 15 month-old child comes to the clinic for a follow-up visit after hospitalization for treatment of Kawasaki Disease. The nurse recognizes that which of the following scheduled immunizations will be
delayed?
MMR
Hib
IPV
DtaP
The correct answer is A: MMR
The nurse is assessing a pregnant client in her third trimester. The parents are informed that the ultrasound suggests that the baby is small for gestational age (SGA). An earlier ultrasound indicated normal growth. The nurse understands that this change is most likely due to what factor?
Sexually transmitted infection
Exposure to teratogens
Maternal hypertension
Chromosomal abnormalities
The correct answer is C: Maternal hypertension
After the shift report in a labor and delivery unit which of these clients would the nurse check first?
A middle aged woman with asthma and diabetes mellitus Type 1 has a BP of 150/94
A middle aged woman with a history of two prior vaginal term births is 2 cm dilated
A young woman is a grand multipara has cervical dilation of 4 cm and 50% effaced
An adolescent who is 18 weeks pregnant has a report of no fetal heart tones and coughing up frothy sputum
The correct answer is D: An adolescent who is 18 weeks pregnant has a report of no fetal heart tones and coughing up frothy sputum
The nurse is caring for an 87 year-old client with urinary retention. Which finding should be reported immediately?
Fecal impaction
Infrequent voiding
Stress incontinence
Burning with urination
The correct answer is A: Fecal impaction
The nasogastric tube of a post-op gastrectomy client has stopped draining greenish liquid. The nurse should
Irrigate it as ordered with distilled water
Irrigate it as ordered with normal saline
Place the end of the tube in water to see if the water bubbles
Withdraw the tube several inches and reposition it
The correct answer is B: Irrigate it as ordered with normal saline
The parents of a child who has recently been diagnosed with asthma ask the nurse to
explain the condition to them. The best response is "Asthma causes…
the airway to become narrow and obstructs airflow."
air to be trapped in the lungs because the airways are dilated."
the nerves that control respiration to become hyperactive."
a decrease in the stress hormones which prevents the airways from opening." The correct answer is A: the airway to become narrow and obstructs airflow."
The nurse is assessing a child with suspected lead poisoning. Which of the following assessments is the nurse most likely to find?
Complaints of numbness and tingling in feet
Wheezing noted when lung sound auscultated
Excessive perspiration
Difficulty sleeping
The correct answer is A: Complaints of numbness and tingling in feet
The nurse is caring for a client with end-stage heart failure. The family members are distressed about the client's impending death. What action should the nurse do first?
Explain the stages of death and dying to the family
Recommend an easy-to-read book on grief
Assess the family's patterns for dealing with death
Ask about their religious affiliations
The correct answer is C: Assess the family''s patterns for dealing with death
The nurse is caring for a client with Meniere's disease. When teaching the client about the disease, the nurse should explain that the client should avoid foods high in
Calcium
Fiber
Sodium
Carbohydrate
The correct answer is C: Sodium
The nurse is teaching a mother who will breast feed for the first time. Which of the following is a priority?
Show her films on the physiology of lactation
Give the client several illustrated pamphlets
Assist her to position the newborn at the breast
Give her privacy for the initial feeding
The correct answer is C: Assist her to position the newborn at the breast
The nurse is taking a health history from parents of a child admitted with possible Reye's Syndrome. Which recent illness would the nurse recognize as increasing the risk to develop Reye's
Syndrome?
Rubeola
Meningitis
Varicella
Hepatitis
The correct answer is C: Varicella
While giving care to a 2 year-old client, the nurse should remember that the toddler's tendency to say "no" to almost everything is an indication of what psychosocial skill?
Stubborn behavior
Rejection of parents
Frustration with adults
Assertion of control
The correct answer is D: Assertion of control
A postpartum client admits to alcohol use throughout the pregnancy. Which of the following newborn assessments suggests to the nurse that the infant has fetal alcohol syndrome?
Growth retardation is evident
Multiple anomalies are identified
Cranial facial abnormalities are noted
Prune belly syndrome is suspected
The correct answer is C: Cranial facial abnormalities are noted
The nurse is attending a workshop about caring for persons infected with Hepatitis. Which statement is correct when referring to the incidence rate for Hepatitis?
The number of persons in a population who develop Hepatitis B during a specific period of time
The total number of persons in a population who have Hepatitis B at a particular time
The percentage of deaths resulting from Hepatitis B during a specific time
The occurrence of Hepatitis B in the population at a particular time
The correct answer is A: The number of persons in a population who develop Hepatitis B during a specific period of time
A 36 year-old female client has a hemoglobin level of 14 g/dl and a hematocrit of 42% following a D&C. Which of the following would the nurse expect to find when assessing this client?
Capillary refill less than 3 seconds
Pale mucous membranes
Respirations 36 breaths per minute
Complaints of fatigue when ambulating
The correct answer is A: Capillary refill less than 3 seconds
The nurse is caring for a client suspected to have Tuberculosis (TB). Which of the following diagnostic tests is essential for determining the presence of active TB? The nurse is caring for a client suspected to have Tuberculosis (TB). Which of the following diagnostic tests is essential for determining the presence of active TB?
Tuberculin skin testing
Sputum culture
White blood cell count
Chest x-ray
The correct answer is B: Sputum culture
The nurse has been teaching an apprehensive primipara who has difficulty in initial nursing of the newborn. What observation at the time of discharge suggests that initial breast feeding is effective?
The mother feels calmer and talks to the baby while nursing
The mother awakens the newborn to feed whenever it falls asleep
The newborn falls asleep after 3 minutes at the breast
The newborn refuses the supplemental bottle of glucose water
The correct answer is A: The mother feels calmer and talks to the baby while nursing
The mother of a burned child asks the nurse to clarify what is meant by a third degree burn. The best response by the nurse is
"The top layer of the skin is destroyed."
"The skin layers are swollen and reddened."
"All layers of the skin were destroyed in the burn."
"Muscle, tissue and bone have been injured."
The correct answer is C: "All layers of the skin were destroyed in the burn."
The nurse is taking a health history from a Native American client. It is critical that the nurse must remember that eye contact with such clients is considered
Expected
Rude
Professional
Enjoyable
The correct answer is B: Rude
A nurse is instructing a class for new parents at a local community center. The nurse would stress that which activity is most hazardous for an 8 month-old child?
Riding in a car
Falling off a bed
Electrical outlets
Eating peanuts
The correct answer is D: Eating peanuts
When teaching parents about sickle cell disease, the nurse should tell them that their child's anemia is caused by
Reduced oxygen capacity of cells due to lack of iron
An imbalance between red cell destruction and production
Depression of red and white cells and platelets
Inability of sickle shaped cells to regenerate
The correct answer is B: An imbalance between red cell destruction and production
The nurse is assessing a newborn delivered at home by an admitted heroin addict. Which of the following would the nurse expect to observe?
Hypertonic neuro reflex
Immediate CNS depression
Lethargy and sleepiness
Jitteriness at 24-48 hours
The correct answer is D: Jitteriness at 24-48 hours
The nurse is caring for a client with congestive heart failure. Which finding requires the nurse's immediate attention?
Pulse oximetry of 85%
Nocturia
Crackles in lungs
Diaphoresis
The correct answer is A: Pulse oximetry of 85%
The nurse is assessing a young child at a clinic visit for a mild respiratory infection. Koplik spots are noted on the oral mucous membranes. The nurse should then assess which area of the body?
Inspect the skin
Auscultate breath sounds
Evaluate muscle strength
Investigate elimination patterns
The correct answer is A: Inspect the skin
Which action is most likely to ensure the safety of the nurse while making a home visit?
Observation during the visit of no evidence of weapons in the home
Prior to the visit, review client's record for any previous entries about violence
Remain alert at all times and leave if cues suggest the home is not safe
Carry a cell phone, pager and/or hand held alarm for emergencies
The correct answer is C: Staying alert at all times and leaving if cues suggest the home is not safe
An adolescent client is admitted in respiratory alkalosis following aspirin overdose. The nurse recognizes that this imbalance was caused by
Tachypnea
Acidic byproducts
Vomiting and dehydration
Hyperpyrexia
The correct answer is A: Tachypnea
The nurse discovers that the parents of a 2 year-old child continue to use an apnea monitor each night. The parents state: “We are concerned about the possible occurrence of sudden infant death
syndrome (SIDS).” In order to take appropriate action, the nurse must understand that
The child is within the age group most susceptible to SIDS
The peak age for occurrence of SIDS is 8 to 12 months of age
The apnea monitor is not effective on a child in this age group
95% of SIDS cases occur before 6 months of age
The correct answer is D: 95% percent of all SIDS cases occur before 6 months
As a client is being discharged following resolution of a spontaneous pneumothorax,
he tells the nurse that he is now going to Hawaii for a vacation. The nurse would warn him to avoid
Surfing
Scuba diving
Parasailing
Swimming
Review Information: The correct answer is B: Scuba diving
The nurse is providing diet instruction to the parents of a child with cystic fibrosis. The nurse would emphasize that the diet should be
High calorie, low fat, low sodium
High protein, low fat, low carbohydrate
High protein, high calorie, unrestricted fat
High carbohydrate, low protein, moderate fat
The correct answer is C: High protein, high calorie, unrestricted fat
A client had arrived in the USA from a developing country 1 week prior. The client is to be admitted to the medical surgical unit with a diagnosis of AIDS with a history of unintended weight loss, drug abuse, night sweats, productive cough and a "feeling of being hot all the time." The nurse should assign the client to share a room with a client with the diagnosis of
Acute tuberculosis with a productive cough of discolored sputum for over three months
Lupus and vesicles on one side of the middle trunk from the back to the abdomen
Pseudomembranous colitis and C. difficile.
Exacerbation of polyarthritis with severe pain
The correct answer is A: Acute tuberculosis with a productive cough of discolored sputum for over three months
A client's admission urinalysis shows the specific gravity value of 1.039. Which of the following assessment data would the nurse expect to find when assessing this client?
Moist mucous membranes
Urinary frequency
Poor skin turgor
Increased blood pressure
The correct answer is C: Poor skin turgor
Parents are concerned that their 11 year-old child is a very picky eater. The nurse
suggests which of the following as the best initial approach?
Consider a liquid supplement to increase calories
Discuss consequences of an unbalanced diet with the child
Provide fruit, vegetable and protein snacks
Encourage the child to keep a daily log of foods eaten
The correct answer is B: Discuss consequences of an unbalanced diet with the child
At a community health fair the blood pressure of a 62 year-old client is 160/96. The client states “My blood pressure is usually much lower.” The nurse should tell the client to
go get a blood pressure check within the next 48 to 72 hours
check blood pressure again in 2 months
see the health care provider immediately
visit the health care provider within 1 week for a BP check
The correct answer is A: go get a blood pressure check within the next 48 to 72 hours
A client is admitted to the emergency room with renal calculi and is complaining of moderate to severe flank pain and nausea. The client’s temperature is 100.8 degrees Fahrenheit. The priority nursing goal for this client is
Maintain fluid and electrolyte balance
Control nausea
Manage pain
Prevent urinary tract infection
The correct answer is C: Manage pain The immediate goal of therapy is to alleviate the client’s pain.
An RN who usually works in a spinal rehabilitation unit is floated to the emergency department. Which of these clients should the charge nurse assign to this RN?
A middle-aged client who says "I took too many diet pills" and "my heart feels like it is racing out of my chest."
A young adult who says "I hear songs from heaven. I need money for beer. I quit drinking 2 days ago for my family. Why are my arms and legs jerking?"
C)An adolescent who has been on pain medications for terminal cancer with an initial assessment finding of pinpoint pupils and a relaxed respiratory rate of 10
D) An elderly client who reports having taken a "large crack hit" 10 minutes prior to walking into the emergency room
The correct answer is c: An adolescent who has been on pain medications for terminal cancer with an initial assessment finding of pinpoint pupils and a relaxed respiratory rate of 10
While planning care for a toddler, the nurse teaches the parents about the expected developmental changes for this age. Which statement by the mother shows that she understands the child's developmental needs?
"I want to protect my child from any falls."
"I will set limits on exploring the house."
"I understand the need to use those new skills."
"I intend to keep control over our child."
The correct answer is C: "I understand the need to use those new skills."
A client who is pregnant comes to the clinic for a first visit. The nurse gathers data about her obstetric history, which includes 3 year old twins at home and a miscarriage 10 years ago at 12 weeks
gestation. How would the nurse accurately document this information?
Gravida 4 para 2
Gravida 2 para 1
Gravida 3 para 1
Gravida 3 para 2
The correct answer is C: Gravida 3 para 1
A child who ingested 15 maximum strength acetaminophen tablets 45 minutes ago is seen in the emergency department. Which of these orders should the nurse do first?
Gastric lavage PRN
Acetylcysteine (mucomyst) for age per pharmacy
Start an IV Dextrose 5% with 0.33% normal saline to keep vein open
Activated charcoal per pharmacy
The correct answer is A: Gastric lavage PRN
The nurse is preparing to administer an enteral feeding to a client via a nasogastric feeding tube. The most important action of the nurse is
Verify correct placement of the tube
Check that the feeding solution matches the dietary order
Aspirate abdominal contents to determine the amount of last feeding remaining in stomach
Ensure that feeding solution is at room temperature
The correct answer is A: Verify correct placement of the tube
The nurse anticipates that for a family who practices Chinese medicine the priority goal would be to
Achieve harmony
Maintain a balance of energy
Respect life
Restore yin and yang
The correct answer is D: Restore yin and yang
Which complication of cardiac catheterization should the nurse monitor for in the initial 24 hours after the procedure?
angina at rest
thrombus formation
dizziness
falling blood pressure
The correct answer is B: thrombus formation
A nurse prepares to care for a 4 year-old newly admitted for rhabdomyosarcoma. The nurse should alert the staff to pay more attention to the function of which area of the body?
The muscles
The cerebellum
The kidneys
The leg bones
The correct answer is A: All striated muscles
A client comes to the clinic for treatment of recurrent pelvic inflammatory disease. The nurse recognizes that this condition most frequently follows which type of infection?
Trichomoniasis
Chlamydia
Staphylococcus
Streptococcus
The correct answer is B: Chlamydia
During the evaluation of the quality of home care for a client with Alzheimer's disease, the priority for the nurse is to reinforce which statement by a family member?
At least 2 full meals a day is eaten.
We go to a group discussion every week at our community center.
We have safety bars installed in the bathroom and have 24 hour alarms on the doors.
The medication is not a problem to have it taken 3 times a day.
The correct answer is C: We have safety bars installed in the bathroom and have 24 hour alarms on the doors.
The nurse is caring for a client with a venous stasis ulcer. Which nursing intervention would be most effective in promoting healing?
Apply dressing using sterile technique
Improve the client's nutrition status
Initiate limb compression therapy
Begin proteolytic debridement
The correct answer is B: Improve the client''s nutrition status
During an assessment of a client with cardiomyopathy, the nurse finds that the systolic blood pressure has decreased from 145 to 110 mm Hg and the heart rate has risen from 72 to 96 beats per minute and the client complains of periodic dizzy spells. The nurse instructs the client to
Increase fluids that are high in protein
Restrict fluids
Force fluids and reassess blood pressure
Limit fluids to non-caffeine beverages
The correct answer is C: Force fluids and reassess blood pressure
Which individual is at greatest risk for developing hypertension?
45 year-old African American attorney
60 year-old Asian American shop owner
40 year-old Caucasian nurse
55 year-old Hispanic teacher
The correct answer is A: 45 year-old African American attorney
The nurse is caring for a client with a serum potassium level of 3.5 mEq/L. The client is placed on a cardiac monitor and receives 40 mEq KCL in 1000 ml of 5% dextrose in water IV. Which of the following EKG patterns indicates to the nurse that the infusions should be discontinued?
Narrowed QRS complex
Shortened "PR" interval
Tall peaked T waves
Prominent "U" waves
The correct answer is C: Tall peaked T waves
A client has been taking furosemide (Lasix) for the past week. The nurse recognizes which finding may indicate the client is experiencing a negative side effect from the medication?
Weight gain of 5 pounds
Edema of the ankles
Gastric irritability
Decreased appetite
The correct answer is D: Decreased appetite
Which of these statements best describes the characteristic of an effective reward- feedback system?
Specific feedback is given as close to the event as possible
Staff are given feedback in equal amounts over time
Positive statements are to precede a negative statement
Performance goals should be higher than what is attainable
The correct answer is A: Specific feedback is given as close to the event as possible
The nurse practicing in a maternity setting recognizes that the post mature fetus is at risk due to
Excessive fetal weight
Low blood sugar levels
Depletion of subcutaneous fat
Progressive placental insufficiency
The correct answer is D: Progressive placental insufficiency
A child who has recently been diagnosed with cystic fibrosis is in a pediatric clinic where a nurse is performing an assessment. Which later finding of this disease would the nurse not expect to see at this
time?
Positive sweat test
Bulky greasy stools
Moist, productive cough
Meconium ileus
The correct answer is C:Moist, productive cough
Which of the following should the nurse implement to prepare a client for a KUB (Kidney, Ureter, Bladder) radiograph test?
Client must be NPO before the examination
Enema to be administered prior to the examination
Medicate client with Lasix 20 mg IV 30 minutes prior to the examination
No special orders are necessary for this examination
The correct answer is D: No special orders are necessary for this examination
The hospital has sounded the call for a disaster drill on the evening shift. Which of these clients would the nurse put first on the list to be discharged in order to make a room available for a new admission?
A middle aged client with a history of being ventilator dependent for over 7 years and admitted with bacterial pneumonia five days ago
A young adult with diabetes mellitus Type 2 for over 10 years and admitted with antibiotic induced diarrhea 24 hours ago
An elderly client with a history of hypertension, hypercholesterolemia and lupus, and was admitted with Stevens- Johnson syndrome that morning
An adolescent with a positive HIV test and admitted for acute cellulitus of the lower leg 48 hours ago
The correct answer is A: A middle aged client with a history of being ventilator dependent for over 7 years and admitted with bacterial pneumonia five days ago
A triage nurse has these 4 clients arrive in the emergency department within 15 minutes. Which client should the triage nurse send back to be seen first?
A 2 month old infant with a history of rolling off the bed and has bulging fontanels with crying
A teenager who got a singed beard while camping
An elderly client with complaints of frequent liquid brown colored stools
A middle aged client with intermittent pain behind the right scapula
The correct answer is B: A teenager who got singed a singed beard while camping
A client is receiving digoxin (Lanoxin) 0.25 mg. Daily. The health care provider has written a new order to give metoprolol (Lopressor) 25 mg. B.I.D. In assessing the client prior to administering the medications, which of the following should the nurse report immediately to the health care provider?
Blood pressure 94/60
Heart rate 76
Urine output 50 ml/hour
Respiratory rate 16
The correct answer is A: Blood pressure 94/60
A nurse enters a client's room to discover that the client has no pulse or respirations. After calling for help, the first action the nurse should take is
Start a peripheral IV
Initiate closed-chest massage
Establish an airway
Obtain the crash cart
The correct answer is C: Establish an airway
A 3 year-old child comes to the pediatric clinic after the sudden onset of findings that include irritability, thick muffled voice, croaking on inspiration, hot to touch, sit leaning forward, tongue protruding, drooling and suprasternal retractions. What should the nurse do first?
Prepare the child for x-ray of upper airways
Examine the child's throat
Collect a sputum specimen
Notify the healthcare provider of the child's status
The correct answer is D: Notify the health care provider of the child''s status
A nurse is to administer meperidine hydrochloride (Demerol) 100 mg, atropine sulfate (Atropisol) 0.4 mg, and promethizine hydrochloride (Phenergan) 50 mg IM to a pre- operative client. Which action should the nurse take first?
Raise the side rails on the bed
Place the call bell within reach
Instruct the client to remain in bed
Have the client empty bladder
The correct answer is D: Have the client empty bladder
In children suspected to have a diagnosis of diabetes, which one of the following complaints would be most likely to prompt parents to take their school age child for evaluation?
Polyphagia
Dehydration
Bed wetting
Weight loss
The correct answer is C: Bed wetting
A client has been newly diagnosed with hypothyroidism and will take levothyroxine (Synthroid) 50 mcg/day by mouth. As part of the teaching plan, the nurse emphasizes that this medication:
Should be taken in the morning
May decrease the client's energy level
Must be stored in a dark container
Will decrease the client's heart rate
The correct answer is A: Should be taken in the morning
A client has a Swan-Ganz catheter in place. The nurse understands that this is intended to measure
Right heart function
Left heart function
Renal tubule function
Carotid artery function
The correct answer is B: Left heart function
Which of these findings indicate that a pump to deliver a basal rate of 10 ml per hour plus PRN for pain break through for morphine drip is not working?
The client complains of discomfort at the IV insertion site
The client states "I just can't get relief from my pain."
The level of drug is 100 ml at 8 AM and is 80 ml at noon
The level of the drug is 100 ml at 8 AM and is 50 ml at noon
The correct answer is C: The level of drug is 100 ml at 8 AM and is 80 ml at noon
The nurse is performing a neurological assessment on a client post right CVA. Which finding, if observed by the nurse, would warrant immediate attention?
Decrease in level of consciousness
Loss of bladder control
Altered sensation to stimuli
Emotional lability
The correct answer is A: Decrease in level of consciousness
When teaching a client with coronary artery disease about nutrition, the nurse should emphasize
Eating 3 balanced meals a day
Adding complex carbohydrates
Avoiding very heavy meals
Limiting sodium to 7 gms per day
The correct answer is C: Avoiding very heavy meals
The nurse is speaking at a community meeting about personal responsibility for health promotion. A participant asks about chiropractic treatment for illnesses. What
should be the focus of the nurse’s response?
Electrical energy fields
Spinal column manipulation
Mind-body balance
Exercise of joints
The correct answer is B: Spinal column manipulation
The home health nurse visits a male client to provide wound care and finds the client lethargic and confused. His wife states he fell down the stairs 2 hours ago. The nurse should
Place a call to the client's health care provider for instructions
Send him to the emergency room for evaluation
Reassure the client's wife that the symptoms are transient
Instruct the client's wife to call the doctor if his symptoms become worse The correct answer is B: Send him to the emergency room for evaluation
While assessing a 1 month-old infant, which finding should the nurse report immediately?
Abdominal respirations
Irregular breathing rate
Inspiratory grunt
Increased heart rate with crying
Review Information: The correct answer is C: Inspiratory grunt
A client with multiple sclerosis plans to begin an exercise program. In addition to discussing the benefits of regular exercise, the nurse should caution the client to avoid activities which
Increase the heart rate
Lead to dehydration
Are considered aerobic
May be competitive
The correct answer is B: Lead to dehydration
The nurse is caring for a client who had a total hip replacement 4 days ago. Which assessment requires the nurse’s immediate attention?
I have bad muscle spasms in my lower leg of the affected extremity.
"I just can't 'catch my breath' over the past few minutes and I think I am in grave danger."
"I have to use the bedpan to pass my water at least every 1 to 2 hours."
"It seems that the pain medication is not working as well today."
The correct answer is B: "I just can''t ''catch my breath'' over the past few minutes and I think I am in grave danger."
The nurse is giving discharge teaching to a client 7 days post myocardial infarction. He asks the nurse why he must wait 6 weeks before having sexual intercourse. What is the best response by the nurse to this question?
"You need to regain your strength before attempting such exertion."
"When you can climb 2 flights of stairs without problems, it is generally safe."
"Have a glass of wine to relax you, then you can try to have sex."
"If you can maintain an active walking program, you will have less risk."
The correct answer is B: "When you can climb 2 flights of stairs without problems, it is generally safe."
What would the nurse expect to see while assessing the growth of children during their school age years?
Decreasing amounts of body fat and muscle mass
Little change in body appearance from year to year
Progressive height increase of 4 inches each year
Yearly weight gain of about 5.5 pounds per year
The correct answer is D: Yearly weight gain of about 5.5 pounds per year
The nurse is assigned to care for a client who has a leaking intracranial aneurysm. To minimize the risk of rebleeding , the nurse should plan to
Restrict visitors to immediate family
Avoid arousal of the client except for family visits
Keep client's hips flexed at no less than 90 degrees
Apply a warming blanket for temperatures of 98 degrees Fahrenheit or less The correct answer is A: Restrict visitors to immediate family
The nurse is performing a gestational age assessment on a newborn delivered 2 hours ago. When comparing findings to the Ballard scale, which situation may affect the score?
Birth weight
Racial differences
Fetal distress in labor
Birth trauma
The correct answer is C: Fetal distress in labor
A 4 year-old hospitalized child begins to have a seizure while playing with hard plastic toys in the hallway. Of the following nursing actions, which one should the nurse do first?
Place the child in the nearest bed
Administer IV medication to slow down the seizure
Place a padded tongue blade in the child's mouth
Remove the child's toys from the immediate area
The correct answer is D: Remove the child’’s toys from the immediate area
A client asks the nurse to explain the basic ideas of homeopathic medicine. The response that best explains this approach is that remedies
Destroy organisms causing disease
Maintain fluid balance
Boost the immune system
Increase bodily energy
The correct answer is C: Boost the immune system
The nurse is caring for a 2 year-old who is being treated with chelation therapy, calcium disodium edetate, for lead poisoning. The nurse should be alert for which of the following side effects?
Neurotoxicity
Hepatomegaly
Nephrotoxicity
Ototoxicity
The correct answer is C: Nephrotoxicity
The nurse is caring for a 1 year-old child who has 6 teeth. What is the best way for the nurse to give mouth care to this child?
Using a moist soft brush or cloth to clean teeth and gums
Swabbing teeth and gums with flavored mouthwash
Offering a bottle of water for the child to drink
Brushing with toothpaste and flossing each tooth
The correct answer is A: Using a moist soft brush or cloth to clean teeth and gums
At a senior citizens meeting a nurse talks with a client who has diabetes mellitus Type 1. Which statement by the client during the conversation is most predictive of a potential for impaired skin
integrity?
"I give my insulin to myself in my thighs."
"Sometimes when I put my shoes on I don't know where my toes are."
"Here are my up and down glucose readings that I wrote on my calendar."
"If I bathe more than once a week my skin feels too dry."
The correct answer is B: "Sometimes when I put my shoes on I don''t know where my toes are."
A couple trying to conceive asks the nurse when ovulation occurs. The woman reports a regular 32 day cycle. Which response by the nurse is correct?
Days 7-10
Days 10-13
Days 14-16
Days 17-19
The correct answer is D: Days 17-19
Included in teaching the client with tuberculosis taking INH about follow-up home care, the nurse should emphasize that a laboratory appointment for which of the following lab tests is critical?
Liver function
Kidney function
Blood sugar
Cardiac enzymes
The correct answer is A: Liver function
A 78 year-old client with pneumonia has a productive cough but is confused. Safety protective devices (restraints) have been ordered for this client. How can the nurse prevent aspiration?
Suction the client frequently while restrained
Secure all 4 restraints to 1 side of bed
Obtain a sitter for the client while restrained
Request an order for a cough suppressant
The correct answer is C: Obtain a sitter for the client while restrained
A client with a fractured femur has been in Russell’s traction for 24 hours. Which nursing action is associated with this therapy?
Check the skin on the sacrum for breakdown
Inspect the pin site for signs of infection
Auscultate the lungs for atelectasis
Perform a neurovascular check for circulation
The correct answer is D: Perform a neurovascular check for circulation
The nurse is caring for a client with extracellular fluid volume deficit. Which of the following assessments would the nurse anticipate finding?
Bounding pulse
Rapid respirations
Oliguria
Neck veins are distended
The correct answer is C: Oliguria
When suctioning a client's tracheostomy, the nurse should instill saline in order to
Decrease the client's discomfort
Reduce viscosity of secretions
Prevent client aspiration
Remove a mucus plug
The correct answer is D: Remove a mucus plug
A woman in her third trimester complains of severe heartburn. What is appropriate teaching by the nurse to help the woman alleviate these symptoms?
Drink small amounts of liquids frequently
Eat the evening meal just before retiring
Take sodium bicarbonate after each meal
Sleep with head propped on several pillows
The correct answer is D: Sleep with head propped on several pillows
A nurse is caring for a client who had a closed reduction of a fractured right wrist followed by the application of a fiberglass cast 12 hours ago. Which finding requires the nurse’s immediate attention?
Capillary refill of fingers on right hand is 3 seconds
Skin warm to touch and normally colored
Client reports prickling sensation in the right hand
Slight swelling of fingers of right hand
The correct answer is C: Client reports prickling sensation in the right hand
A newborn is having difficulty maintaining a temperature above 98 degrees Fahrenheit and has been placed in a warming isolate. Which action is a nursing priority?
Protect the eyes of the neonate from the heat lamp
Monitor the neonate’s temperature
Warm all medications and liquids before giving
Avoid touching the neonate with cold hands The correct answer is B: Monitor the
neonate’s temperature
The nurse is caring for a client with a myocardial infarction. Which finding requires the nurse's immediate action?
Periorbital edema
Dizziness spells
Lethargy
Shortness of breath
The correct answer is B: Dizziness spells
A client is admitted with the diagnosis of pulmonary embolism. While taking a history, the client tells the nurse he was admitted for the same thing twice before, the last time just 3 months ago. The
nurse would anticipate the health care provider ordering
Pulmonary embolectomy
Vena caval interruption
Increasing the coumadin therapy to an INR of 3-4
Thrombolytic therapy
The correct answer is B: Vena cava interruption
A 70 year-old woman is evaluated in the emergency department for a wrist fracture of unknown causes. During the process of taking client history, which of these items should the nurse identify as related to the client’s greatest risk factors for osteoporosis?
Menopause at age 50
Has taken high doses of steroids for arthritis for many years
Maintains an inactive lifestyle for the past 10 years
Drinks 2 glasses of red wine each day for the past 30 years The correct answer is B: Takes steroids for arthritis
Decentralized scheduling is used on a nursing unit. A chief advantage of this management strategy is that it
Considers client and staff needs
Conserves time for planning
Frees the nurse manager to handle other priorities
Allows for requests about special privileges
The correct answer is A: Considers client and staff needs
A newborn has hyperbilirubinemia and is undergoing phototherapy with a blanket. Which safety measure is most important during this process?
Regulate the neonate’s temperature using a radiant heater
Withhold feedings while under the phototherapy
Provide water feedings at least every 2 hours
Protect the eyes of neonate from the phototherapy lights
The correct answer is C: Provide water feedings at least every 2 hours
The nurse is at the community center speaking with retired people. To which comment by one of the retirees during a discussion about glaucoma would the nurse give a supportive comment to reinforce correct information?
"I usually avoid driving at night since lights sometimes seem to make things blur."
"I take half of the usual dose for my sinuses to maintain my blood pressure."
"I have to sit at the side of the pool with the grandchildren since I can't swim with this eye problem."
"I take extra fiber and drink lots of water to avoid getting constipated."
The correct answer is D: "I take extra fiber and drink lots of water to avoid getting constipated."
On daily cleaning of a tracheostomy, the client coughs and displaces the tracheostomy tube. The nurse could have avoided this by
placing an obturator at the client’s bedside
having another nurse assist with the procedure
fastening clean tracheostomy ties before removing old ties
Withdraw catheter in a circular motion
The correct answer is C: fastening clean tracheostomy ties before removing old ties
Which contraindication should the nurse assess for prior to giving a child immunizations?
Mild cold symptoms
Chronic asthma
Depressed immune system
Allergy to eggs
The correct answer is C: Depressed immune system
The nurse is teaching home care to the parents of a child with acute spasmodic croup. The most important aspect of this care is
Sedation as needed to prevent exhaustion
Antibiotic therapy for 10 to 14 days
Humidified air and increased oral fluids
Antihistamines to decrease allergic response
The correct answer is C: Humidified air and increased oral fluids
A newborn delivered at home without a birth attendant is admitted to the hospital for observation. The initial temperature is 35 degrees Celsius (95 degrees Fahrenheit) axillary. The nurse recognizes that cold stress may lead to what complication?
Lowered BMR
Reduced PaO2
Lethargy
Metabolic alkalosis
The correct answer is B: Reduced PaO2
In addition to standard precautions, a nurse should implement contact precautions for which client?
60 year-old with herpes simplex
6 year-old with mononucleosis
45 year-old with pneumonia
3 year-old with scarlet fever
The correct answer is A: 60 year-old with herpes simplex
Which of the following situations is most likely to produce sepsis in the neonate?
Maternal diabetes
Prolonged rupture of membranes
Cesarean delivery
Precipitous vaginal birth
The correct answer is B: Prolonged rupture of membranes
Which client is at highest risk for developing a pressure ulcer?
23 year-old in traction for fractured femur
72 year-old with peripheral vascular disease, who is unable to walk without assistance
75 year-old with left sided paresthesia and is incontinent of urine and stool
30 year-old who is comatose following a ruptured aneurysm
The correct answer is C: 75 year-old client with left sided paresthesia and is incontinent
of urine and stool
A new nurse manager is responsible for interviewing applicants for a staff nurse position. Which interview strategy would be the best approach?
Vary the interview style for each candidate to learn different techniques
Use simple questions requiring "yes" and "no" answers to gain definitive information
C) Obtain an interview guide from human resources for consistency inn interviewing each candidate
D) Ask personal information of each applicant to assure meeting of job demands The correct answer is C: Obtain an interview guide from human resources for consistency in interviewing each candidate
A client who is 12 hour post-op becomes confused and says: “Giant sharks are swimming across the ceiling.” Which assessment is necessary to adequately identify the source of this client's behavior?
Cardiac rhythm strip
Pupillary response
Pulse oximetry
Peripheral glucose stick
The correct answer is C: Pulse oximetry
A client returns from surgery after an open reduction of a femur fracture. There is a small bloodstain on the cast. Four hours later, the nurse observes that the stain has doubled in size. What is the best action for the nurse to take?
Call the health care provider
Access the site by cutting a window in the cast
Record the findings in the nurse's notes only
Outline the spot with a pencil and note the time and date on thecast
The correct answer is D: Outline the spot with a pencil and note the time and date on the cast
A nurse assessing the newborn of a mother with diabetes understands that hypoglycemia is related to what pathophysiological process?
Disruption of fetal glucose supply
Pancreatic insufficiency
Maternal insulin dependency
Reduced glycogen reserves
The correct answer is A: Disruption of fetal glucose supply
The nurse is teaching a parent about side effects of routine immunizations. Which of the following must be reported immediately?
Irritability
Slight edema at site
Local tenderness
Temperature of 102.5 F
The correct answer is D: Temperature of 102.5 F
The parents of a toddler ask the nurse how long their child will have to sit in a car seat while in the automobile. What is the nurse’s best response to the parents?
“Your child must use a care seat until he weighs at least 40 pounds."
The child must be 5 years of age to use a regular seat belt.
“Your child must reach a height of 50 inches to sit in a seat belt."
“The child can use a regular seat belt when he can sit still."
The correct answer is A: “Your child must use a care seat until he weighs at least 40 pounds."
A 16 year-old boy is admitted for Ewing's sarcoma of the tibia. In discussing his care with the parents, the nurse understands that the initial treatment most often includes
Amputation just above the tumor
Surgical excision of the mass
Bone marrow graft in the affected leg
Radiation and chemotherapy
The correct answer is D: Radiation and chemotherapy
A client complains of some discomfort after a below the knee amputation. Which action by the nurse is appropriate to do initially?
Conduct guided imagery or distraction
Ensure that the stump is elevated for the initial day
Wrap the stump snugly in an elastic bandage
Administer opioid narcotics as ordered
The correct answer is B: Ensure that the stump is elevated for the initial day
What is the best way that parents of pre-schoolers can begin teaching their child about injury prevention?
Set good examples themselves
Protect their child from outside influences
Make sure their child understands all the safety rules
Discuss the consequences of not wearing protective devices
The correct answer is A: Set good examples themselves
Which oxygen delivery system would the nurse apply that would provide the highest concentrations of oxygen to the client?
Venturi mask
Partial rebreather mask
Non-rebreather mask
Simple face mask
The correct answer is C: Non-rebreather mask
The nurse is teaching the mother of a 5 month-old about nutrition for her baby. Which statement by the mother indicates the need for further teaching?
"I'm going to try feeding my baby some rice cereal."
"When he wakes at night for a bottle, I feed him."
"I dip his pacifier in honey so he'll take it."
"I keep formula in the refrigerator for 24 hours."
The correct answer is C: "I dip his pacifier in honey so he''ll take it."
The nurse is performing an assessment on a client who is cachectic and has developed an enterocutaneous fistula following surgery to relieve a small bowel obstruction. The client's total protein level is reported as 4.5. Which of the following would the nurse anticipate?
Additional potassium will be given IV
Blood for coagulation studies will be drawn
Total parenteral nutrition (TPN) will be started
Serum lipase levels will be evaluated
The correct answer is C: Total parenteral nutrition (TPN) will be started
A newborn weighed 7 pounds 2 ounces at birth. The nurse assesses the newborn at home 2 days later and finds the weight to be 6 pounds 7 ounces. What should the nurse tell the parents about this
weight loss?
The newborn needs additional assessments
The mother should breast feed more often
A change to formula is indicated
The loss is within normal limits
The correct answer is D: The loss is within normal limits
During a situation of pain management, which statement is a priority to consider for the ethical guidelines of the nurse?
The client's self-report is the most important consideration
Cultural sensitivity is fundamental to pain management
Clients have the right to have their pain relieved
Nurses should not prejudge a client's pain using their own values
The correct answer is A: The client''s self report is the most important consideration
A 35-year-old client of Puerto Rican-American descent is diagnosed with ovarian cancer. The client states “I refuse both radiation and chemotherapy because they are 'hot.'” The next action for the nurse to take is to
Document the situation in the notes
Report the situation to the health care provider
Talk with the client's family about the situation
Ask the client to talk about the concerns about the "hot"treatments
The correct answer is D: Ask the client to talk about the concerns about the "hot" treatments
Which of the following drugs should the nurse anticipate administering to a client before they are to receive electroconvulsive therapy?
Benzodiazepines
Chlorpromazine (Thorazine)
C) Succinylcholine (Anectine)
D) Thiopental sodium (Pentothal Sodium)
The correct answer is C: Succinylcholine (Anectine)
A client is brought to the emergency room following a motor vehicle accident. When assessing the client one-half hour after admission, the nurse notes several physical changes. Which changes would require the nurse's immediate attention?
Increased restlessness
Tachycardia
Tracheal deviation
Tachypnea
The correct answer is C: Tracheal deviation
Which approach is a priority for the nurse who works with clients from many
different cultures?
Speak at least 2 other languages of clients in the neighborhood
Learn about the cultures of clients who are most often encountered
Have a list of persons for referral when interaction with these clients occur
Recognize personal attitudes about cultural differences and real or expected biases The correct answer is D: Recognize personal attitudes about cultural differences and real or expected biases
A client with chronic obstructive pulmonary disease (COPD) and a history of coronary artery disease is receiving Aminophylline, 25mg/hour. Which one of the following findings by the nurse would require immediate intervention?
Decreased blood pressure and respirations.
Flushing and headache.
Restlessness and palpitations.
Increased heart rate and blood pressure.
The correct answer is C: Restlessness and palpitations.
The nurse is planning care for an 8 year-old child. Which of the following should be included in the plan of care?
Encourage child to engage in activities in the playroom
Promote independence in activities of daily living
Talk with the child and allow him to express his opinions
Provide frequent reassurance and cuddling
The correct answer is A: Encourage child to engage in activities in the playroom
.
A pregnant client who is at 34 weeks gestation is diagnosed with a pulmonary embolism (PE). Which of these mediations would the nurse anticipate the health care provider ordering?
Oral Coumadin therapy
Heparin 5000 units subcutaneously b.i.d.
Heparin infusion to maintain the PTT at 1.5-2.5 times the control value
Heparin by subcutaneous injection to maintain the PTT at 1.5 times the control value The correct answer is D: Heparin by subcutaneous injection to maintain the PTT at 1.5 times the control value
The nurse is caring for a client with Hodgkin's disease who will be receiving radiation therapy. The nurse recognizes that, as a result of the radiation therapy, the client is most likely to experience
High fever
Nausea
Face and neck edema
Night sweats
The correct answer is B: Nausea
While assessing the vital signs in children, the nurse should know that the apical heart rate is preferred until the radial pulse can be accurately assessed at about what age?
1 year of age
2 years of age
3 years of age
4 years of age
The correct answer is B: 2 years of age
Which of these clients, who all have the findings of a board-like abdomen, would the nurse suggest that the health care provider examine first?
An elderly client who stated that "My awful pain in my right side suddenly stopped about 3 hours ago."
A pregnant woman of 8 weeks newly diagnosed with an ectopic pregnancy
A middle-aged client admitted with diverticulitis and has taken only clear liquids for the past week
A teenager with a history of falling off a bicycle and did not hit the handle bars The correct answer is A: An elderly client who stated that "My awful pain in my right side suddenly stopped about 3 hours ago."
A client with a panic disorder has a new prescription for Xanax (Alprazolam). In teaching the client about the drug's actions and side effects, which of the following should the nurse emphasize?
Short-term relief can be expected
The medication acts as a stimulant
Dosage will be increased as tolerated
Initial side effects often continue
The correct answer is A: Short-term relief can be expected
Which of these questions is priority when assessing a client with hypertension?
"What over-the-counter medications do you take?"
"Describe your usual exercise and activity patterns."
"Tell me about your usual diet."
"Describe your family's cardiovascular history."
The correct answer is A: "What over-the-counter medications do you take?"
During a routine check-up, an insulin-dependent diabetic has his glycosylated hemoglobin checked. The results indicate a level of 11%. Based on this result, what teaching should the nurse emphasize?
Rotation of injection sites
Insulin mixing and preparation
Daily blood sugar monitoring
Regular high protein diet
The correct answer is C: Daily blood sugar monitoring
Which of these clients would the nurse monitor for the complication of C. difficile diarrhea?
An adolescent taking medications for acne
An elderly client living in a retirement center taking prednisone
A young adult at home taking a prescribed amino glycoside
A hospitalized middle aged client receiving clindamycin
The correct answer is D: A hospitalized middle aged client receiving clindamycin
The nurse is assessing a comatose client receiving gastric tube feedings. Which of the following assessments requires an immediate response from the nurse?
Decreased breath sounds in right lower lobe
Aspiration of a residual of 100cc of formula
Decrease in bowel sounds
Urine output of 250 cc in past 8 hours
The correct answer is A: Decreased breath sounds in right lower lobe
The nurse is preparing to take a toddler's blood pressure for the first time. Which of the following actions should the nurse do first?
Explain that the procedure will help him to get well
Show a cartoon character with a blood pressure cuff
Explain that the blood pressure checks the heart pump
Permit handling the equipment before putting the cuff in place The correct answer is D: Permit handling the equipment
before putting the cuff in place
A 72 year-old client is scheduled to have a cardioversion. A nurse reviews the client’s medication administration record. The nurse should notify the health care
provider if the client received which medication during the preceding 24 hours?
digoxin (Lanoxin)
diltiazam (Cardizem)
nitroglycerine ointment
metoprolol (Toprol XL)
The correct answer is A: digoxin (Lanoxin)
To prevent drug resistance common to tubercle bacilli, the nurse is aware that which of the following agents are usually added to drug therapy?
Anti-inflammatory agent
High doses of B complex vitamins
Amino glycoside antibiotic
Two anti-tuberculosis drugs
The correct answer is D: Two anti-tuberculosis drugs
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